The POSSUM System of Surgical Audit Graham Paul Copeland, ChM urgical audit is not a new phenomenon. as early as 1750 sc, King Hammurabi of Baby- on issued decrees for the punishment of negligent physicians, particularly surgeons. In such a decree discovered at Susa in Iran and inscribed on a 2-m-high black diorite stone, Hammurabi states that: adoctor inflicts a serious wound with his op- eration knifeon a free man's slave and kills hit, the doctor must replace the slave with an- other, Ifa doctor has treated a free man but catised a serious injury from which the man ties, oF fhe has opened an abscess and the man goes blind, the man isto et off his hands Not surprisingly, internal medicine rather than surgery was popular at that time. In- deed, to many surgeons today, this edict siill seems to be exacted in a sublimated The outcome of surgical interven tion, whether death or uncomplicated sur- vival, complications, or long-term morbid- ity, isnot solely dependent on the abilities of the surgeon in isolation. The patients physiological status, the disease that re- quires surgical correction, the nature of the ‘operation, and the preoperative and post- operative support services have a major elfect on the ultimate outcome. It is ev dent to surgeons worldwide that raw mor- tality and morbidity rates do little to ex- pound these differences, and that the use of such statistics is at best inaccurate and at worst dangerous. When taken to an ex- treme, mortality rates can achieve what ap- pears to be a self-fulfilling prophecy. The ‘unit that selects only low-risk cases achieves alow mortality rate and therefore attracts more patients, perhaps undeservedly, whereas the unit that cannot select only low-risk cases s left with a worsening case mix, and their performance as judged by ‘mortality rate will appear to deteriorate sil further over time. From the Department of Surgery, Warrington Hospital, Warrington, England. (©2002 American Med With this in mind, during the 1980s a system was developed to allow for the first time an assessment of surgical qual- fay that was risk adjusted for the patient's acute and chronic physiological status and for the nature of the operation. By using 8 process of multivariate discriminant analysis, a scoring system was developed that could accurately predict 30-day mor- tality and morbidity rates, The POSSUM audit system (Physiological and Opera- live Severity Score for the Enumeration of Morality and Morbidity)! was designed 10 be easy and rapid to use and to have wide application across the general surgical spectrum, both in the elective and emer- gency settings, and to be applicable in most health care systems = The POSSUM system isa 2-part scor- Ing system that includes a physiological as- sessment and a measure of operative se- verity. The physiological part of the score Includes 12 variables, each divided into 4 grades with an exponentially increasing score (1, 2, 4, and 8) (Figure 1). The physiological variables are those appar- ent atthe time of surgery and include clin cal symptoms and signs, results of simple biochemical and hematological investiga- tions, and electrocardiographic changes. Ifa particular variable is not available, a score ofl isallocated. Some variables may be assessed by means of clinical symp- toms or signs or by means of changes on chest radiographic findings. The mini- ‘mum score, therefore, is 12, with a maxi- ‘mum score of 88. The operative severity part of the score includes 6 variables, each divided 1 Association, All rights reserved.a ea Taga So eo a ep +a Lau bead Mec = ee fee 7 | hn a = [Ss a oe, ee i Bane ox | ma seta, |tetmany Seay [eR Pas — ae] in ee = Be == | cone ‘aman fiom [w]e [as | Elian © [iee | Bet ‘sine ‘exation | stirs st * ortlood™ a or md | swacono | use coao [ameter Rar [Ra | Ta, | Da | Mietie change ess Hy = Prosthesis loose? - rao Sa eee] Oa ae ee a ‘pea oom, | Bae, hy soo-03 | c0g0 Spe 100%), however, are possible i linear models are used, and this isa major dan- ger of the Portsmouth POSSUM adaptation.” However, Within the normal range, both a linear and logistic model will yield similar results if the appropriate mathematical methods are used.” Surgical procedures for patients with predictions of mortality exceeding 95% rarely result in asticcessful out- come. Whate indings of the audit of "surgical suc cess,” the patient with a high prediction of death or com- plication but for whom no such adverse outcome occurs often has more to teach us than our failures. In my own on, AI rights reserved,‘Table 1. Examples of Magnitude for General Surgery® Minor emia Vise vein Miro peril surgry Serta surgery Minar TURT Excision af lage subcutaneous sion lntrmedate (pen choleystctory Laparscopie cholecystectomy Appendecory Excision tein equring rating o minor Miro anpuation “hyo bectory jor Laparotomy an sma-bowel resection Colonic restton rater resection Major amputation Nonaortvesciar surgery Cholestctomy ard exploration of il uct ‘ol thyroidectomy jor ‘Abdonioperina excson of ret Donte surgery Whip reseeion Fada tal gastrectomy “STURT indeataewancureiral resection of ua, unit, such a success audit has identified groups of pa- jents, in particular the high-risk patient with a perfo- rated viscus, in whom more rapid resuscitation and sur- gery can produce better outcomes.” This group of patients certainly does not benefit from prolonged attempts at re- suscitation without rapid surgieal intervention, By using the predictions from individual patients, {Lis possible to extrapolate from groups of patients the likely number of adverse outcomes and thus obtain a risk- adjusted quality measure. This measure, the ratio of ob- served number of adverse outcomes to predicted num- ber ofadverse outcomes (OE ratio), can be used to assess differences between surgeons and to observe changes over lime. A ratio of 1.00 indicates average performance; gre: than 1.00, performance worse than expected; and less than 1.00, performance better than expected.” These defini- ons remain the mainstay of application of the O/E r= o in general surgery, although models have been de- signed recently that use the POSSUM system to assess, risk-adjusted length of hospital stay for comparative pur- poses." Using the O/E ratio, we ean assess overall surgeon, performance across the whole range of general and or thopedic surgery. Examples of variability in mortality and ‘morbidity rates, with their attendant O/E ratios, are shown for one unit in Table 3. This clearly demonstrates the danger of using raw mortality and morbidity at parative audit. Not surprisingly, vascular surgeons have forcom- Pe een Cs Se a 7 Ter aS [Hoo waa] Cates cee poms [ome Teme Pg 7 = tice = se |S Te ee sa i Biome cw | aap, | comes [Bagg [SO Fe cy |e | a Bins Fagan [wena [ome fas Pee | RN VT Bean | Sages | Ela cin at | con | etc aye Paes ag) ie Soe [gag [* [Bry [Bn [Be | aa So a are) BSR 2 tai [2 Saad | TE | none == Tee PER on an a PEF ea pen oe Coma maar Pace a” vaio rere [ors Ute Cees pe fae [aw as] oe Hens - D1iypotnsion | % as [a [an Comune Diesvatie ft Be [ES : , we [rsae [eng me Naess ore me [= lee [a tn nm 2 onan ee [ea Tam | ea | oss change on Sane ans Figure 2. Orthopediscre se (©2002 American Medi {ore POSSUM ey. Abrevitons are defined inthe legend oF 1 Association, All rights reserved.‘Table 2. Examples of Operative Magnitude {or Orthopedic Surgery Minor Fasciotary, Ganglontbursa “enotomyfendon repair. Endoscopic joint surgery Carpal tunneinerve release Farol wil (Goeed reduction fracture Inarmedae Exciowtatomy of smal one Mir ot repacement -Arputation af iit) (ose rection vith external ation (pen eduction of small bone acre Major (stotomyofng bone Ligaments reconstruction and posteee Anodes of gent Mairi replacement ‘Amputation of ib Disk surgery pan redctn of ong bone fracture Mare Facial umoratomy Majer spinal reconstruction Rision prostatic replacement of major in. Hina infor smpuation ‘Table 3, Raw and Risk-Adjusted Outcome Measures {or 12 Monts in One Unit” serrate ORs Tomm woman! Wom woman} surgeoyspectaty oranty morvany Woranty moray ‘aur ca TC] BMepaobilary = «251000 Cobre 20151009 Diesel 35185 oge ne Elaaromestnl = 3101.08 Frio 03 21 os ars Girciogy 1D 40 top ‘comes An OF rat of 00 ness aucomes exec: es than 400 eutcomes ethan preted and geste than D0 outers ors than predicted ahigher mortality rate; gastroenterological surgeons, the highest morbidity rate; and urologic surgeons, the low- ‘est mortality and morbidity rates, The POSSUM system, has found wide application for such comparative pur- poses, having been used ina wide variety of surgical sub- specialities ranging from vascular surgery” to gastroen- terology* and coloproctology."' and to more specialized areas such as bariatric surgery” and lung resection." EX- amples of its use in orthopedic surgery are illustrated in Table 4. The POSSUM system has also been found to have wide application in greatly varying health care sys- tems throughout the world (Table 8) All predictions will have confidence limits depen- dent on the number of operations performed and on the number of adverse outcomes, Overreaction should be (©2002 American Med Table 4. Variability In Raw and Risk-Adjusted Outcome Data {in Orthopedic Surgery During 12 Months 7 cot Fallente Of allo ‘surgeon —faortaty —_woriety|—aoraity wor * 30 we io oar 5 " 05 og ta c 2a a om aa 0 14 46 i010 E 21 06 i102 F 26 yr ) 6 23 uz om 08 VE ainda aio observed numberof abets outcomes praicted numberof adverse outzors. An OF ra of 10 ness, bcomes a expected les than 1.0. outtomes beter tan predict Sd greater tan 100, outcomes wore than prada [ebleS amples of he Aplatin of te POSSUM Sytem 3 Units in Countries With Varying Numbers eo OF rato unt Fallents Moray % fer Moria Wargo Ergand 006 a2 000 Inga ‘0 52 101 Tuy 126 38 000 Nalaia 24 56 1m “The POSSUM ss nda te Physiol and Opa Seer Score ofthe rueraton of aay and arly OF rata ab observed ruber of adverse outcomes preiced nber of arse oucomes. An FE fa of 1.00 inats outcomes as expec les than 00, outcomes bats than price, ad grt han 1.00, autores wrs than prada avoided, and the cause of deficiencies in quality should be carefully examined. In a published data set from my ‘own tit, an apparent deficiency in one surgeon was due to aprocess change at ward level in anticoagulation pro- phylaxis administration.’ This was rapidly identified and corrected with minimal morbidity overall and without penalizing the surgeon inappropriately. Variation in out- come will occur over time, but if deteriorating O/E ra- os can be identified early, remedial action can be taken Early rend analysis for morbidity can identify early down- tums in performance before this is replaced with mor- tality. Sudden death after surgery sa rare event, and death usually follows series of antecedent complications. This fact is often forgotten by systems that assess death only as an end point, and is pethaps one of the major advan- tages of the POSSUM system over other audit scoring, ©The POSSUM system can assess differences be- ‘ovcen individual units and departments and allow com- parison over time, Table 6 illustrates minor variations In O/E ratio over time in one surgeon's performance, but more major variation can also occur. Table 7 illus- trates downturn in performance within one unit, which on closer inquiry was associated with an increase in mor- bidity, in particular renal and respiratory complica- tions. This appeared to correlate with a sudden local d crease in availability of intensive care unit beds and resulted ina need to transfer patients to neighboring hos- 1 Association, All rights reserved.‘Table 6, Variations in Annual Performance of One Surgeon During 6 Years* eat Palen Of Rate woroaty —aoranty marty 167 0% oar 185 101 100 0 oor st 0 oor 08 eo 12 101 ue 098 095 “Al pants undergoing scaring reprsont those undegcng inpatient surgery OF ra indeates rato of observed numberof bers outcomes {opted number of adverse utcomes. tO ratio 10 fates, ‘ulomes a pet fe tha 0, etcomes batt than predcaad (restr han 1.00, outcomes wore han preted ‘Table 7. Effect of Intensive Care Unit Bed Avallabllity on fk Adjusted Oteome of Operative nervenion in One Unit? OE Rate ‘vata of i Intonava care Unt Boas, ——_‘Worta ori 700 oa? a ‘0 0 a9 n 108 ‘06 5 120 ‘8 Bed avalabty i expressed as a perarage fhe ol beds tha shoud hae been aaiebl at any aa time. On cecasons whan buds wee not anal, gant wera rarsterred to nghboring uns CF ra ndeaas fata of eberved numberof adverse outcome opadcted numberof ‘Sbvte utcomss, An OE rao 00 ndeats outcomes a ypctd es than 100 outtomisbetr han pedeted, and rata han 100, uteames| worse than predicted pitals. In the transferred group, the O/E ratio was 1.60; in the resident group, the O/E ratio Was 0.98. Corrective action was rapidly taken, with a subsequent fall in O/E, ratio to acceptable levels. Surgery and in particular re suscilative measures are never stalic over time. An in- creasing number of units in North America and Europe are identifying the benefits of preoperative and periop- ‘erative resuscitation in high-risk patients.'°!" With a mor- tality risk between 20% 10 80%, this group of patients has the most to gain from optimization, The POSSUM sys- tem can allow for changes over time in our medical treat- ment. Ifcare should improve significantly, O/E ratios will {all worldwide and simple adjustments in the logistic re- _Bfession equations can he made to continue to allow com- parison over time. Unfortunately, no equation adjust- ment has been necessaty during the past 10 years, At first ‘lance, this may appear disappointing, but on closer re- View, the number of procedures being performed in the high-risk patient group has steadily increased during the past 3 years. In England, there has been a 30% inerease in procedures in patients whose risk for death exceeds 20% and a 12% increase in procedures in patients whose risk exceeds 40, The POSSUM system, therefore, offers many differ- ing facets. allows a numerical prediction of mortality and morbidity for an individual patient It allows com- parative audit providing a method of adjustment of case ‘mix. Itallows comparison to be made over me and ean be easily adjusted to radical changes in health eare in the future. Only by using systems of this type will the com- parative audit become a reality rather than a fantasy" and, for the fist time, will the public and the medical profession trust in outcome measures, Hammuraby’s meth- ods have been in operation for 4000 years; perhaps now fs the time to change. Corresponding author and reprints: Graham Paul Cope- land, ChM, Warrington Hospital, Lovely Lane, Warriy ton, Cheshire WAS 1G, England. kz” 1. Copan GP. sonas , Wars M. POSSUNE a erg syst rural ak si Br Surg. 109178:85 60, 2 Jes HS, Cossar Rickson in sug patas. Br Sug 100938 vas7 {Copan GP, Jone, Vileax A, Ha. Compare acura ug he POSSUM scering stm. Aa Cal Sr ng 1998 75:175-177 4 Soar PH Harte MN MF J Tar BA Coplné GP. Comparison i= Vid surgeon's pertormace Dis Clon ecu. 186 3854-58, 5 Copsand GP. Spa P Brenan tal Rk ade anes of gon p= formance Br Su, 196 0:408-41. 6 CopsandGP Asessng te suger 10 yeas xperns wth be POSSUM ys- tem J in xeon, 200028710 7 Pach, Whiley MS gps WeaverP, Prout WG, Powel’ POSSUM tn Posh POSSUM for rdeing ory. BJ Sug. 1986851217 20 8 Wasinghe LO, Mabon T, Scot OLA, erie OC, Kot Kester RE Com- parison of POSSUM ze Porsauh prec suabonorpreicng th feng asus sara. 7d Su, 199635 200212. 8 Metro ler A Copsand GPK R.A meron properave = ssn Surg 10812-1408, 10. Copsland GP Be, Meio 8, ahwa, War. ring gh stay ingenetal surge Heath Tens. 190720818 1. Takis, Koa, one ea peat malty us aang ur ons: comparison of POSSUM and p-POSSUM searing Systems nase Inesinal suger. Dis Colo Rectum 200015 1526-152 12 Wang Tui Cll reaion wth barum enamine ery case nai he POSSUM sorig system. J Gaston 1098.8 20 205. 18 Cajgas., sedan. Ingo A Aoplesion ote POSSUM ystemin bx ian suger. Obs Sug 10098270281, 14. Brana A Fant, Kune, Geta B Mat A Cala Evan of he POSSUM searing syst nung surgery. Toa Cardinse Sup. 88846: ur 1, Gotcha Maga tae S.Can POSSUM scaing ssa for paige surgi ek red postpeatie cnet? Aa led Oayama 08 saa5 a4, 16. Shoaraer WC, Appl PL, Kram HB, VaxmanK Lee. Prospciv alt supranamal vues of survivors s therapeu goal in high-k surgeal tons Chest 198794 117-186 17. Boyd 0, Grounés AM, Soma ED. A randomized cilia fe tt ot selberae prperave ieee in vapen dlry on meal hghsk Surge ates ANO 105 270-2600-2707 18 Wisc Woods, Fane ta Reducing te ik aol super ‘andossd contol wal eepntiveaptinsaten lange dey. IU. ‘one 000103. 10, Copaand GP. Surge scorng sk assesamentand the surgeon. J al Sug Ed 12-45-48 20. Copel GP Conpuaie au eeu rl Su, ODHO42425 lation, All rights reserved.